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November 16, 2010

Department of Health and Human ServicesOffice of Consumer Information and Insurance Oversight, Office of OversightAttention J ames Mayhew, Room 737-F-04200 Independence Ave. SWWashington, DC 20201

Dear Mr. Mayhew:

Andersen Corporation is interested in applying for a waiver from the restricted annual

limits set forth in the interim final regulations under the Patient Protection and AffordableCare Act for three of our medical plans. The waiver would apply for the plan yearbeginning on J anuary 1, 2011 and ending on December 31, 2011.

The information on the plans is listed below:

Feature Andersen Corporation Plan Provision

Terms of the Plans forWhich the Waiver isBeing Sought

See the attached SPDs for the Silver Line New J erseyUnion Drivers and Grandfathered Production Plan(Plan U), Silver Line New Jersey Union ProductionMedical Plan (Plan T1/T2) and the Silver Line Illinois

Union Production Medical Plan (Plan P2). Page 5 ofeach SPD has an overview of the coverage providedby each plan. These plans are offered to unionemployees at our Silver Line Window business. Theyhave employees primarily in New J ersey and Illinois.

Number of IndividualsCovered by ThesePlans

As of November 16 there are employees enrolledin the Silver Line New J ersey Union Drivers andGrandfathered Production Plan (Plan U);employees enrolled in the Silver Line New J erseyUnion Production Medical Plan (Plan T1/T2); andemployees enrolled in the Silver Line Illinois Union

Production Medical Plan (Plan P2).Annual Limits andRates Associated withThese Plans

The annual limits of $ per member and$ per member are specified in the attachedSPDs and the excerpts from the union contracts. The2010 2011 weekly employee rates are attached asExhibit A and are taken from the union contracts.

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11/3/2011

2

Feature Andersen Corporation Plan Provision

Reason thatCompliance with theInterim Final

Regulations wouldIncrease Premiums

According to our actuary, if Silver Line increased theannual limit in all three plans to $750,000, the 2011cost of the plans (total premium) would increase by

approximately This is a significant impact tothe business. S is faced with attempting torenegotiate the plan design and/or employeecontributions with the union to better reflect the cost ofthe plan that was in place prior to health care reformbeing passed. The plan design must be significantlyreduced to pay for the removal of the annual limits. Ifwe are not successful in renegotiating the plan design,Silver Line may have to eliminate jobs to account forthe increase in costs to the business. A spreadsheetdepicting the increase to the business is attached as

Exhibit B.Attestation I attest that these plans were in force prior toSeptember 23, 2010 and that applying an annual limitof $750,000 to these plans would result in a significantincrease in premiums paid by Andersen Corporationfor health care coverage for our employees.

If you have any questions about this letter, please contact me directly at 651-264-2836.

Sincerely,

Kathy ProndzinskiDirector, Corporate Benefits DesignAndersen Corporation100 Fourth Avenue NorthBayport, MN 55003

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1

Lancey, Brandon (CMS/OSORA)

From: Prondzinski, Kathy [Kathy.Prondzinski@AndersenCorp.com]Sent: Wednesday, December 01, 2010 6:11 PMTo: OCIIO OversightSubject: FW: Waiver - 2nd request

At tachments: PPACA limited benefits waiver letter - 11-16-2010 FINAL.doc; Exhibit A and Exhibit B - 2011Actuarial Support of cost increase of hc reform.xls; 2010 Silver Line Plan U SPD_FINAL_ 614 10.pdf; 2010 Silver Line Plan T1 SPD_FINAL_ 6 14 10.pdf; 2010 Silver Line Plan P2SPD_FINAL_12 9 09.pdf; Silver Line NJ Union Contract.tif; Silver Line IL ProductionContract.tif

Importance: High

To whom it may concern:

Although I know that HHS has 30 days in which to determine if we will be granted a waiver, our union has refused tocontinue to bargain until we hear back from HHS on whether or not a waiver has been granted. I therefore am respectfullyasking if there is an answer to our request for a waiver yet. The sooner we hear back, the sooner we can proceed witheither informing our associates that the annual limits will remain in place, and that their plan will remain unchanged, or, inthe case that the waiver is not granted, continuing to bargain with the union and try to offset the additional cost of raising

the limits by changing plan design and/or increasing contributions.

Your attention to this matter is greatly appreciated.

Kathy Prondzinski

Kathy ProndzinskiDirector, Corporate Benefits DesignAndersen Corporation100 Fourth Avenue NorthBayport, MN 55003

Tel: 651-264-2836 Fax: 651-275-6585kprondzinski@andersencorp.comThink of the environment before you print!

From: Prondzinski, KathySent: Tuesday, November 16, 2010 2:03 PMTo:OCIIOOversight@hhs.govCc:

Subject: WaiverImportance: HighAttached please find:

Andersen Corporations application for waiver from the restricted annual limits set forth in the interim finalregulations under the Patient Protection and Affordable Care Act (PPACA) Exhibits A and B (actuarial support of the cost impact of health care reform and employee contributions for 2010

and 2011) Summary Plan Descriptions (SPDs) for the three plans for which we are requesting a waiver Excerpts from the Silver Line New J ersey Union Contract and The Silver Line Illinois Production Union Contract,

outlining the employee contribution agreements with the company

Should you need any further information, please feel free to contact me, using the information below.

Thank you,

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2

Kathy Prondzinski

Kathy ProndzinskiDirector, Corporate Benefits DesignAndersen Corporation100 Fourth Avenue NorthBayport, MN 55003

Tel: 651-264-2836 Fax: 651-275-6585

kprondzinski@andersencorp.com

Think of the environment before you print!

Right-click heretpictures.To helpprivacy,Outlookautomatic downlopicturefromtheTheenvironmenbusinesspartner.Corporation hasan ENERGY STAPartner oftheYe

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11/15/2010

Contract Expires

Dependent Eligibility

Deductible

Out-of-Pocket Max

Calendar Year Max

Lifetime Maximum

Coinsurance

Preventive Care

Office Visit

Inpatient Facility

IP/OP Surgery

ER

NJ Grandfathered Production & Drivers Plan

All dependents to age 26

Illinois Pro

March 1, 2013

All dependents to age 26

NJ Production Plan

2010 SL IL Union

Production

Union Plan P2

2011 SL NJ Union

GP & Drivers (U)

Union Plan A

2010 SL NJ Union

Production (T1/T2)

Union Plan B

March 1, 2013

In-Network In-Network

March 1, 2013

In-Network In-Network

February 1, 2011

No out of network coverage

$750,000

$750,000

Prescription Drug

2011 SL NJ Union

Production (T1/T2)

Union Plan B

Required HC Reform Changes

2010 SL NJ Union

GP & Drivers (U)

Union Plan A

In-Network

Required HC Reform Changes

March 1, 2013

Benefit Percentage Impact fr om 2010 Design

Actuarial Rates EE EE EE

Employee Contributions CountRate EE Mthly EE% Rate EE Mthly EE% Co CountRate EE Mthly EE%Employee Only (T2) Employee Only Employee +Spouse Employee +Children Family Total Cost Change Total Cost

% Change Total Cost

Co Cost

Projected Change Co Cost

% Change Co Cost

EE Cost

Projected Change EE Cost

% Change EE Cost

2010 Un ion Plan (U) A 2011 Union Plan (U) A

2010 Union Plan (T1/T2) B

2010 IL Prod Plan P2

2011 Union Plan (T1/T2) B

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Silver Line Union Employee Weekly Contributions

Silver Line NJ Union Medical Plan Weekly Employee Contributions

Contract Language

Count 2010 2011 2012 Count 2010 2011 2012

Employee Only Employee OnlyEmployee +Spouse Employee +SpouseEmployee+Child(ren) Employee +Childr(reFamily Family

Total Contributions $Annual Increase * Silver Line IL Union Production Medical Plan Weekly Employee Contributions

* Silver Line Illinois Union Contract Lang ontract expires Feb. 1,Employee Only Employee +Spouse Employee+Child(ren) Family

Total Contributions Annual Increase

Increases in premium cost shall be shared with the company payin

and the employee paying of the increase provided that the

Employee's share be capped a per week p ontract year.If the same language remains for 2011, it is a increase with the c

* NOTE: this contract expires Feb. 1, 2011. These employee contributions ar

illustrative ONLY based on current the contract language and are subject to

change after negotiations begin Dec. 2010

EXHIBIT A

Union Plan A (Grandfathered Production & Drivers - U) Union Plan B (Product ion - T1/T2)

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:

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///co-adshare/...s/DFOI%20Processing%20Team/Brandon/Andersen%20Corporation/Reqeust%20for%20info%20response%2012.20.10.htm[11/03/2011 4:09

rom: Prondzinski, Kathy [Kathy.Prondzinski@AndersenCorp.com]ent: Monday, December 20, 2010 4:28 PMo: Habit, Sandra (HHS/OCIIO)

Cc: Parrucci, Tammyubject: RE: Waiver Application - Andersen Corporation

Attachments: waiver_application_forms_.zipttached please find:

I. The completed annual limits spreadsheets.II. The following information is also being provided as requested:

I am confirming that the plan was created pursuant to the Taft-Hartley Act. The expiration of the last collective

bargaining agreement is December 31, 2012.

I confirm that the plan was in existence before March 23, 2010. We will be complying with the requirements of th

Grandfathering Regulation, 45 CFR 147.140.

his should constitute a complete application. As stated in our earlier emails, time is of the essence, due to the suspension of our

ollectively bargained negotiations. A timely response is most appreciated.

Kathy Prondzinski

irector, Corporate Benefits Design

ndersen Corporation

00 Fourth Avenue Northayport, MN 55003

el: 651-264-2836 Fax: 651-275-6585

prondzinski@andersencorp.com

Think of the environment before you print!

rom: Habit, Sandra (HHS/OCIIO) [mailto:Sandra.Habit@hhs.gov]ent: Thursday, December 16, 2010 2:05 PMo: Prondzinski, Kathyubject: Waiver Application - Andersen Corporation

Ms. Prondzinski,hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (P

Act) Section 2711. In order to expedite your application, please provide the following information:. Please complete the entire annual limits spreadsheet, available at:ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed spreadsheet to this emaddress as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell shouldontain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None, anrovide an explanation regarding why you are unable to complete that particular cell in a separate document.

I. In addition, please provide the following information:

Confirm whether the plan was created pursuant to the Taft-Hartley Act. And if so, please state the expiration of t

ast collective bargaining agreement.

Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying wit

requirements of the Grandfathering Regulation, 45 CFR 147.140?Once this information is received and the application is complete, it will be processed by the Department of Health an

Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision wi0 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decis

hank you,ANDERSEN:000234

mailto:kprondzinski@andersencorp.comhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlmailto:kprondzinski@andersencorp.com

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///co-adshare/...s/DFOI%20Processing%20Team/Brandon/Andersen%20Corporation/Reqeust%20for%20info%20response%2012.20.10.htm[11/03/2011 4:09

andy

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

01-492-4175

andra.Habit@hhs.gov

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly

sclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed,

opied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full extent o

w.

_________________________________________________________________________________________________________

o Whom It May Concern:

n November 16, 2010, Andersen Corporation submitted to HHS an application for a waiver from the restricted annual limits set fo

the interim final regulations under the Patient Protection and Affordable Care Act for three of its medical plans. The waiver wouldpply for the plan year beginning on January 1, 2011 and ending on December 31, 2011.

We understand that HHS intends to rule on complete waiver applications within 30 days of receipt. Therefore, we anticipate receivi

esponse by the close of business today, Thursday, December 16 th.

s stated in our earlier email (below), time is of the essence due to the suspension of critically important collective bargaining

egotiations with our union. A further bargaining session is scheduled Monday, December 20 th in anticipation of receiving a respon

our waiver application by December 16 th. If we do not receive a timely response from HHS, the bargaining process will be delay

rther to the prejudice of the Company, the Union and the employees.

our attention and cooperation are greatly appreciated.

athy

Kathy Prondzinski

irector, Corporate Benefits Design

ndersen Corporation

00 Fourth Avenue North

ayport, MN 55003

el: 651-264-2836 Fax: 651-275-6585

prondzinski@andersencorp.com

rom: Prondzinski, Kathyent: Wednesday, December 01, 2010 5:11 PMo: OCIIOOversight@hhs.govubject: FW: Waiver - 2nd requestmportance: High

o whom it may concern:

lthough I know that HHS has 30 days in which to determine if we will be granted a waiver, our union has refused to continue to

argain until we hear back from HHS on whether or not a waiver has been granted. I therefore am respectfully asking if there is an

nswer to our request for a waiver yet. The sooner we hear back, the sooner we can proceed with either informing our associates

e annual limits will remain in place, and that their plan will remain unchanged, or, in the case that the waiver is not granted,

ontinuing to bargain with the union and try to offset the additional cost of raising the limits by changing plan design and/or increas

ontributions.

ANDERSEN:000235

mailto:Sandra.Habit@hhs.govmailto:kprondzinski@andersencorp.commailto:kprondzinski@andersencorp.commailto:Sandra.Habit@hhs.gov

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our attention to this matter is greatly appreciated.

athy Prondzinski

Kathy Prondzinski

irector, Corporate Benefits Design

ndersen Corporation

00 Fourth Avenue North

ayport, MN 55003

el: 651-264-2836 Fax: 651-275-6585prondzinski@andersencorp.com

Think of the environment before you print!

rom: Prondzinski, Kathyent: Tuesday, November 16, 2010 2:03 PMo: OCIIOOversight@hhs.govc:ubject: Waivermportance: High

ttached please find: Andersen Corporations application for waiver from the restricted annual limits set forth in the interim final regulations und

the Patient Protection and Affordable Care Act (PPACA)

Exhibits A and B (actuarial support of the cost impact of health care reform and employee contributions for 2010 and 2011

Summary Plan Descriptions (SPDs) for the three plans for which we are requesting a waiver

Excerpts from the Silver Line New Jersey Union Contract and The Silver Line Illinois Production Union Contract, outlining

employee contribution agreements with the company

hould you need any further information, please feel free to contact me, using the information below.

hank you,

athy Prondzinski

Kathy Prondzinski

irector, Corporate Benefits Design

ndersen Corporation

00 Fourth Avenue North

ayport, MN 55003

el: 651-264-2836 Fax: 651-275-6585

prondzinski@andersencorp.com

Think of the environment before you print!

ANDERSEN:000236

mailto:kprondzinski@andersencorp.commailto:kprondzinski@andersencorp.commailto:kprondzinski@andersencorp.commailto:kprondzinski@andersencorp.com

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///co-adshare/...20Torres/DFOI%20Processing%20Team/Brandon/Andersen%20Corporation/Request%20for%20info%2012.16.10.htm[11/03/2011 4:09

rom: Habit, Sandra (HHS/OCIIO)ent: Thursday, December 16, 2010 3:05 PM

To: 'Kathy.Prondzinski@AndersenCorp.com'ubject: Waiver Application - Andersen Corporation

Ms. Prondzinski,hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act

PHS Act) Section 2711. In order to expedite your application, please provide the following information:. Please complete the entire annual limits spreadsheet, available at:

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed spreadsheet to this eddress as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell shouontain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None,nd/or provide an explanation regarding why you are unable to complete that particular cell in a separate documentI. In addition, please provide the following information:

Confirm whether the plan was created pursuant to the Taft-Hartley Act. And if so, please state the expiration o

he last collective bargaining agreement.

Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying w

the requirements of the Grandfathering Regulation, 45 CFR 147.140?Once this information is received and the application is complete, it will be processed by the Department of Healthnd Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a deci

within 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waecision.

hank you,andy

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

01-492-4175

andra.Habit@hhs.gov

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly

sclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribu

r copied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full e

f the law.

ANDERSEN:000237

http://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlmailto:Sandra.Habit@hhs.govmailto:Sandra.Habit@hhs.govhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html

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ANNUAL LIMIT WAIVER APPLICATION

Ann ual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

App licant

(Plan/ Policy

Situs) City

App licant

(Plan/

Policy

Situs)

State

Plan/ Policy

Effective Date

(mm/dd/yyyy)

Contact

Name

Street

Address City State Zip Code

Phone

Number

(including

area code)

Email

Address

C

(e.

Be

Rx o

Silver Line

Building

Products,

LLC.

Silver Line

Illinois Union

Production

Medical P lan Minneapolis MN 01/01/2011

Kathy

Prondzinski

100 Fourth

Ave N Bayport MN 55003

651-264-

2836

kathy.prondzi

nski@anders

encorp.com Lim

Silver Line

Building

Products,

Silver Line

Illinois Union

Production Kathy 100 Fourth 651-264-

kathy.prondzi

nski@anders

LLC. Medical Plan Minneapolis MN 01/01/2011 Prondzinski Ave N Bayport MN 55003 2836 encorp.com Lim

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless itdisplays a valid OMB control number. The information collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, includinsearch existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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ANNUAL LIMIT WAIVER APPLICATION

Ambul ator y Emerg ency Hosp italizatio n Laboratory Pediat ri c

Maternity/

Newborn

Mental Health/

Substance

Abuse

Rehabilitative/

Devices

Preventive/

Wellness

Current Essential Benefits An nual Limits (Annu al Limit fo r Each Essential Benefit)

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ANNUAL LIMIT WAIVER APPLICATION

ndividual/ Employee

Tier*

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)*:

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver Granted

(in dollars)*

Projected Rate Increase that woul d result

from compliance with $750,000 Annual Limit

Restriction (in d ollars) (Average Premium

by Individual)*

Employee +Family

* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (ifpremiums are a range based on years of service or age) and by tier (Employee, Employee +Spouse, Employee +Child, Family,etc.) as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column AN, AQ and AT).

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ANNUAL LIMIT WAIVER APPLICATION

Ann ual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

App licant

(Plan/ Policy

Situs) City

App licant

(Plan/

Policy

Situs)

State

Plan/ Policy

Effective Date

(mm/dd/yyyy)

Contact

Name

Street

Address City State Zip Code

Phone

Number

(including

area code)

Email

Address

C

(e.

Be

Rx o

Silver Line

Building

Products,

LLC.

Silver Line

New J ersey

Union

Grandfathere

d Production

and Driver

Medical P lan Minneapolis MN 01/01/2011

Kathy

Prondzinski

100 Fourth

Ave N Bayport MN 55003

651-264-

2836

kathy.prondzi

nski@anders

encorp.com Lim

Silver Line

Building

Products,

LLC.

Silver Line

New J ersey

Union

Grandfathere

d Production

and Driver

Medical P lan Minneapolis MN 01/01/2011

Kathy

Prondzinski

100 Fourth

Ave N Bayport MN 55003

651-264-

2836

kathy.prondzi

nski@anders

encorp.com Lim

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless itdisplays a valid OMB control number. The

information collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, includinsearch existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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ANNUAL LIMIT WAIVER APPLICATION

Ambul ator y Emerg ency Hosp italizatio n Laboratory Pediat ri c

Maternity/

Newborn

Mental Health/

Substance

Abuse

Rehabilitative/

Devices

Preventive/

Wellness

Current Essential Benefits An nual Limits (Annu al Limit fo r Each Essential Benefit)

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ANNUAL LIMIT WAIVER APPLICATION

ndividual/ Employee

Tier*

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

Projected Rate Increase that would result

from c ompliance with $750,000 Annual Limit

Restriction (in dollars) (Average Premium

by Individual)*

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)*:

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver Granted

(in dollars)*

Employee +Family

* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (ifpremiums are a range based on years of service or age) and by tier (Employee, Employee +Spouse, Employee +Child, Family,etc.) as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column AN, AQ and AT).

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ANNUAL LIMIT WAIVER APPLICATION

Ann ual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

App licant

(Plan/ Policy

Situs) City

App licant

(Plan/

Policy

Situs)

State

Plan/ Policy

Effective Date

(mm/dd/yyyy)

Contact

Name

Street

Address City State Zip Code

Phone

Number

(including

area code)

Email

Address

C

(e.

Be

Rx o

Silver Line

Building

Products,

LLC.

Silver Line

New J ersey

Union

Production

Medical P lan Minneapolis MN 01/01/2011

Kathy

Prondzinski

100 Fourth

Ave N Bayport MN 55003

651-264-

2836

kathy.prondzi

nski@anders

encorp.com Lim

Silver Line

Silver Line

New J ersey

BuildingProducts,

LLC.

UnionProduction

Medical P lan Minneapolis MN 01/01/2011

Kathy

Prondzinski

100 Fourth

Ave N Bayport MN 55003

651-264-

2836

kathy.prondzinski@anders

encorp.com Lim

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless itdisplays a valid OMB control number. The information collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, includinsearch existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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ANNUAL LIMIT WAIVER APPLICATION

Ambul ator y Emerg ency Hosp italizatio n Laboratory Pediat ri c

Maternity/

Newborn

Mental Health/

Substance

Abuse

Rehabilitative/

Devices

Preventive/

Wellness

Current Essential Benefits An nual Limits (Annu al Limit fo r Each Essential Benefit)

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ANNUAL LIMIT WAIVER APPLICATION

ndividual/ Employee

Tier*

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)*:

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver Granted

(in dollars)*

Projected Rate Increase that woul d result

from compliance with $750,000 Annual Limit

Restriction (in d ollars) (Average Premium

by Individual)*

Employee +Family

* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (ifpremiums are a range based on years of service or age) and by tier (Employee, Employee +Spouse, Employee +Child, Family,etc.) as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column AN, AQ and AT).

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///co-adshare/...pproval%20Letter%20for%20a%20Waiver%20of%20the%20Annual%20Limits%20Requirements%2012-30-2010.htm[11/03/2011 4:09:

rom: Habit, Sandra (HHS/OCIIO)ent: Thursday, December 30, 2010 3:16 PM

To: 'kathy.prondzinski@andersencorp.com'ubject: Andersen Corporation Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010

Attachments: Updated Jan 1 Approval Letter .pdf

ood Afternoon,

hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Actection 2711 for Andersen Corporation. HHS has reviewed your application and made its determination.

lease see the attached letter. The following plans have been approved:

Silver Line

New Jersey

Union

Grandfathered

Production

and Driver

Medical Plan

Silver Line

New JerseyUnion

Grandfathered

Production

and Driver

Medical Plan

Silver Line

New Jersey

Union

Production

Medical Plan

Silver Line

New JerseyUnion

Production

Medical Plan

Silver Line

Illinois Union

Production

Medical Plan

Silver Line

Illinois Union

Production

Medical Plan

lease confirm receipt of this letter by replying to this e-mail.

lease let me know if I can be of further assistance.

incerely,

ANDERSEN:000247

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///co-adshare/...pproval%20Letter%20for%20a%20Waiver%20of%20the%20Annual%20Limits%20Requirements%2012-30-2010.htm[11/03/2011 4:09:

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

01-492-4175

andra.Habit@hhs.gov

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly

sclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribu

r copied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full e

f the law.

ANDERSEN:000248

mailto:Sandra.Habit@hhs.govmailto:Sandra.Habit@hhs.gov

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///co-adshare/...FOI%20Processing%20Team/Brandon/Andersen%20Corporation/Approval%20receipt%2012.30.10.htm[11/03/2011 4:09

rom: Prondzinski, Kathy [Kathy.Prondzinski@AndersenCorp.com]Sent: Thursday, December 30, 2010 4:45 PMo: Habit, Sandra (HHS/OCIIO)

Subject: Re: Andersen Corporation Approval Letter for a Waiver of the Annual Limits Requirements 12-010hank you for your very prompt response to our request. I confirm receipt of our approval of the Silver Line union plans.

rom: Habit, Sandra (HHS/OCIIO) [mailto:Sandra.Habit@hhs.gov]ent: Thursday, December 30, 2010 02:15 PM

o: Prondzinski, Kathyubject: Andersen Corporation Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010

ood Afternoon,

hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act

ection 2711 for Andersen Corporation. HHS has reviewed your application and made its determination.

lease see the attached letter. The following plans have been approved:

Silver Line

New Jersey

Union

GrandfatheredProduction

and Driver

Medical Plan

Silver Line

New Jersey

Union

Grandfathered

Production

and Driver

Medical Plan

Silver Line

New JerseyUnion

Production

Medical Plan

Silver Line

New Jersey

Union

Production

Medical Plan

Silver Line

Illinois Union

ProductionMedical Plan

Silver Line

Illinois Union

Production

Medical Plan

lease confirm receipt of this letter by replying to this e-mail.

ANDERSEN:000249

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///co-adshare/...FOI%20Processing%20Team/Brandon/Andersen%20Corporation/Approval%20receipt%2012.30.10.htm[11/03/2011 4:09

lease let me know if I can be of further assistance.

incerely,

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

01-492-4175andra.Habit@hhs.gov

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly

sclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribu

r copied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full e

f the law.

ANDERSEN:000250

mailto:Sandra.Habit@hhs.govmailto:Sandra.Habit@hhs.gov

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///co-adshare/...0Waivers%20-%20Torres/DFOI%20Processing%20Team/Brandon/Andersen%20Corporation/Completion%2012.21.10.htm[11/03/2011 4:09

rom: Habit, Sandra (HHS/OCIIO)ent: Tuesday, December 21, 2010 10:51 AMo: 'Prondzinski, Kathy'ubject: RE: Waiver Application - Andersen Corporation

December 21, 2010

Ms. Prondzinski,

hank you for your information.

Your application is now complete and you will receive a determination of your application within 30 days. Take careave a happy holiday!

hank you,andy

rom: Prondzinski, Kathy [mailto:Kathy.Prondzinski@AndersenCorp.com]ent: Monday, December 20, 2010 4:28 PMo: Habit, Sandra (HHS/OCIIO)

c: Parrucci, Tammyubject: RE: Waiver Application - Andersen Corporation

ttached please find:

I. The completed annual limits spreadsheets.

II. The following information is also being provided as requested:

I am confirming that the plan was created pursuant to the Taft-Hartley Act. The expiration of the last collective

bargaining agreement is December 31, 2012.

I confirm that the plan was in existence before March 23, 2010. We will be complying with the requirements of th

Grandfathering Regulation, 45 CFR 147.140.

his should constitute a complete application. As stated in our earlier emails, time is of the essence, due to the suspension of our

ollectively bargained negotiations. A timely response is most appreciated.

Kathy Prondzinski

irector, Corporate Benefits Design

ndersen Corporation

00 Fourth Avenue North

ayport, MN 55003

el: 651-264-2836 Fax: 651-275-6585

prondzinski@andersencorp.com

Thi nk of the environment before you print!

rom: Habit, Sandra (HHS/OCIIO) [mailto:Sandra.Habit@hhs.gov]ent: Thursday, December 16, 2010 2:05 PMo: Prondzinski, Kathyubject: Waiver Application - Andersen Corporation

Ms. Prondzinski,hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (P

Act) Section 2711. In order to expedite your application, please provide the following information:ANDERSEN:000251

mailto:kprondzinski@andersencorp.commailto:kprondzinski@andersencorp.com

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. Please complete the entire annual limits spreadsheet, available at:ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed spreadsheet to this emaddress as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell shouldontain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None, anrovide an explanation regarding why you are unable to complete that particular cell in a separate document.

I. In addition, please provide the following information:

Confirm whether the plan was created pursuant to the Taft-Hartley Act. And if so, please state the expiration of t

ast collective bargaining agreement.

Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying witrequirements of the Grandfathering Regulation, 45 CFR 147.140?

Once this information is received and the application is complete, it will be processed by the Department of Health anHuman Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision wi

0 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decis

hank you,andy

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight01-492-4175

andra.Habit@hhs.gov

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly

sclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed,

opied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full extent o

w.

_________________________________________________________________________________________________________

o Whom It May Concern:

n November 16, 2010, Andersen Corporation submitted to HHS an application for a waiver from the restricted annual limits set fo

the interim final regulations under the Patient Protection and Affordable Care Act for three of its medical plans. The waiver would

pply for the plan year beginning on January 1, 2011 and ending on December 31, 2011.

We understand that HHS intends to rule on complete waiver applications within 30 days of receipt. Therefore, we anticipate receivi

esponse by the close of business today, Thursday, December 16 th.

s stated in our earlier email (below), time is of the essence due to the suspension of critically important collective bargaining

egotiations with our union. A further bargaining session is scheduled Monday, December 20 th in anticipation of receiving a respon

our waiver application by December 16 th. If we do not receive a timely response from HHS, the bargaining process will be delay

rther to the prejudice of the Company, the Union and the employees.

our attention and cooperation are greatly appreciated.

athy

Kathy Prondzinski

irector, Corporate Benefits Design

ndersen Corporation

00 Fourth Avenue North

ayport, MN 55003

ANDERSEN:000252

http://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlmailto:Sandra.Habit@hhs.govmailto:Sandra.Habit@hhs.govhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html

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el: 651-264-2836 Fax: 651-275-6585

prondzinski@andersencorp.com

rom: Prondzinski, Kathyent: Wednesday, December 01, 2010 5:11 PMo: OCIIOOversight@hhs.govubject: FW: Waiver - 2nd requestmportance: High

o whom it may concern:

lthough I know that HHS has 30 days in which to determine if we will be granted a waiver, our union has refused to continue to

argain until we hear back from HHS on whether or not a waiver has been granted. I therefore am respectfully asking if there is an

nswer to our request for a waiver yet. The sooner we hear back, the sooner we can proceed with either informing our associates

e annual limits will remain in place, and that their plan will remain unchanged, or, in the case that the waiver is not granted,

ontinuing to bargain with the union and try to offset the additional cost of raising the limits by changing plan design and/or increas

ontributions.

our attention to this matter is greatly appreciated.

athy Prondzinski

Kathy Prondzinski

irector, Corporate Benefits Design

ndersen Corporation

00 Fourth Avenue North

ayport, MN 55003

el: 651-264-2836 Fax: 651-275-6585

prondzinski@andersencorp.com

Thi nk of the environment before you print!

rom: Prondzinski, Kathyent: Tuesday, November 16, 2010 2:03 PM

o: OCIIOOversight@hhs.govc:ubject: Waivermportance: High

ttached please find:

Andersen Corporations application for waiver from the restricted annual limits set forth in the interim final regulations und

the Patient Protection and Affordable Care Act (PPACA)

Exhibits A and B (actuarial support of the cost impact of health care reform and employee contributions for 2010 and 2011

Summary Plan Descriptions (SPDs) for the three plans for which we are requesting a waiver

Excerpts from the Silver Line New Jersey Union Contract and The Silver Line Illinois Production Union Contract, outlining

employee contribution agreements with the company

hould you need any further information, please feel free to contact me, using the information below.

hank you,

athy Prondzinski

Kathy Prondzinski

irector, Corporate Benefits Design

ndersen Corporation

00 Fourth Avenue North

ayport, MN 55003

ANDERSEN:000253

mailto:kprondzinski@andersencorp.commailto:kprondzinski@andersencorp.commailto:kprondzinski@andersencorp.commailto:kprondzinski@